2010 American Heart Association

Part 6: Electrical Therapies
Automated External Defibrillators, Defibrillation, Cardioversion, and Pacing
2010 American Heart Association Guidelines for Cardiopulmonary
Resuscitation and Emergency Cardiovascular Care
Mark S. Link, Chair; Dianne L. Atkins; Rod S. Passman; Henry R. Halperin; Ricardo A. Samson;
Roger D. White; Michael T. Cudnik; Marc D. Berg; Peter J. Kudenchuk; Richard E. Kerber
Overview
This chapter presents guidelines for defibrillation with manual
defibrillators and automated external defibrillators
(AEDs), synchronized cardioversion, and pacing. AEDs may
be used by lay rescuers and healthcare providers as part of
basic life support. Manual defibrillation, cardioversion, and
pacing are advanced life support therapies.
Defibrillation Plus CPR:
A Critical Combination
Early defibrillation is critical to survival from sudden cardiac
arrest (SCA) for several reasons 1 : the most frequent initial
rhythm in out-of-hospital witnessed SCA is ventricular fibrillation
(VF), 2 the treatment for ventricular fibrillation is defibrillation, 3
the probability of successful defibrillation diminishes rapidly over
time, 4 and VF tends to deteriorate to asystole over time. 1,5,6
Several studies have documented the effects of time to
defibrillation and the effects of bystander CPR on survival
from SCA. For every minute that passes between collapse and
defibrillation, survival rates from witnessed VF SCA decrease
7% to 10% if no CPR is provided. 1 When bystander
CPR is provided, the decrease in survival rates is more
gradual and averages 3% to 4% per minute from collapse to
defibrillation. 1,2,5,7 CPR can double 1,3 or triple 4 survival from
witnessed SCA at most intervals to defibrillation.
If bystanders provide immediate CPR, many adults in VF
can survive with intact neurologic function, especially if
defibrillation is performed within 5 to 10 minutes after
SCA. 8,9 CPR prolongs VF, delays the onset of asystole, 10–12
and extends the window of time during which defibrillation
can occur. Basic CPR alone, however, is unlikely to terminate
VF and restore a perfusing rhythm.
New Recommendations to Integrate CPR and
AED Use
To treat VF SCA, rescuers must be able to rapidly integrate CPR
with use of the AED. To give the victim the best chance of
survival, 3 actions must occur within the first moments of a
cardiac arrest 1 : activation of the emergency medical services
(EMS) system, 2 provision of CPR, and operation of an AED. 3
When 2 or more rescuers are present, activation of EMS and
initiation of CPR can occur simultaneously.
Delays to either the start of CPR or the start of defibrillation
reduce survival from SCA. In the 1990s, some predicted that
CPR could be rendered obsolete by the widespread development
of community AED programs. However, Cobb 9 noted that as
more of Seattle’s first responders were equipped with AEDs,
survival rates from SCA unexpectedly fell. This decline was
attributed to reduced emphasis on CPR, and there is growing
evidence to support this view. Part 5: “Adult Basic Life Support”
summarizes the evidence on the importance of provision of
high-quality CPR (including chest compressions of adequate
rate and depth, allowing full chest recoil after each compression
and minimizing interruptions in compressions).
Two critical questions about integration of CPR with
defibrillation were evaluated during the 2010 International
Consensus Conference on CPR and Emergency Cardiovascular
Care. 13 The first question concerned whether CPR
should be provided before defibrillation is attempted. The
second question concerned the number of shocks to be
delivered in a sequence before the rescuer resumes CPR.
Shock First Versus CPR First
When any rescuer witnesses an out-of-hospital arrest and an AED is
immediately available on-site, the rescuer should start CPR and use
the AED as soon as possible. Healthcare providers who treat cardiac
arrest in hospitals and other facilities with AEDs on-site should
provide immediate CPR and should use the AED/defibrillator as
soon as it is available. These recommendations are designed to
support early CPR and early defibrillation, particularly when an
AED is available within moments of the onset of SCA.
In studies in which EMS call-to-arrival intervals were 4 9 to 5 8
minutes or longer, 1 1 ⁄2 to 3 minutes of CPR before defibrillation
increased the rate of initial resuscitation (return of spontaneous
circulation or ROSC), survival to hospital discharge, 8,9 and
1-year survival 8 when compared with immediate defibrillation
The American Heart Association requests that this document be cited as follows: Link MS, Atkins DL, Passman RS, Halperin HR, Samson RA, White
RD, Cudnik MT, Berg MD, Kudenchuk PJ, Kerber RE. Part 6: electrical therapies: automated external defibrillators, defibrillation, cardioversion, and
pacing: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation.
2010;122(suppl 3):S706–S719.
(Circulation. 2010;122[suppl 3]:S706–S719.)
© 2010 American Heart Association, Inc.
Circulation is available at http://circ.ahajournals.org DOI: 10.1161/CIRCULATIONAHA.110.970954
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